Choose on of the following

I am the patient requesting the information for myself

I am the patient requesting the information to be sent to a physician or health practitioner

I am a parent (or legal guardian) of the patient and requesting their information

I am a physician or health practioner

Patient Information *

First Name

Last Name

Date of Birth

MM

DD

YYYY

Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date of Patient Information Request

MM

DD

YYYY

Check all that apply

Initial Consult / Doctor's Notes

Psychological Assessments / Therapy Notes

Video Record of a treatment

Others (ie. insurance papers)

If requesting a Video Record of a treatment, please select the treatment date.

Note: Processing time for Video Records may take up to 30 days. Costs for a single Video Recording from a treatment session is $150 CAD + GST.

MM

DD

YYYY

Choose one of the following

Please note, requests for multiple copies may incur additional costs.

Email

Printed copy available for pickup at clinic

Digital Copy

Physical Copy

Health authority and status

Guardian or trustee appointed under the Adult Guardianship and Trusteeship Act, AND requested information relates to powers and duties of guardian or trustee.

Nearest relative under the Mental Health Act AND requested information is needed to carry out my obligations as the nearest relative.

Agent under the Personal Directives Act AND directive has been enacted AND requested information is relevant to a decision the agent is authorized to make.

Personal representative of a deceased individual AND requested information relates to administration of the individual’s estate.

Power of attorney has been granted by the individual AND requested information relates to powers and duties of attorney.

Written authorization has been given by the individual to make request on his/her behalf.